OUTBREAK MANAGEMENT PLAN -

GUIDELINES FOR PREVENTION AND HANDLING COVID-19 ONBOARD

Appendix 2

COVID-19
Health Declaration
The use is intended for
1. All people coming onboard as far as practicable
2. One form per person and MUST be completed

If answer "YES" to any of below questions, follow below instructions:

1. Consult Crewing/ Vessel Manager, who will take the decision if need to take the person on board.
2. If yes, limit risk by taking required precautions per company correspondence.

No~ QUESTIONNAIRE YES/NO

1 Do you have any of the following symptoms now or within the last 14 days: Cough, smell/taste
impairment, fever, breathing difficulties, body aches, headaches, fatigue, sore throat, diarrhea, NU
and/ or runny nose {even if your symptoms are mild)?
2 Have you been in contact with anyone who is suspected to have or/has been diagnosed
with Covid-19 within the last 14 days? N1'
Enter details -

If any of the above questions is answered yes, please provide details in the above box.
In addition, please provide details below if you have been vaccinated.
Type of vaccine{s):
Total amount of doses:
Date of most recent dose:
Place and Country where administered:

I certify that the above declaration is true and correct to the best of my knowledge and that any dishonest
answers may have serious pub/ichealth implications.

Name
u\ ot\Date
1
AM'-\

Company name (as applicable) Contact details (mobile/office number)

Revision: 7 Valid From: 2022-12-05 Prep.BY: DR App. By: CC Page: 20 of 43